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Referral form for wellbeing workshops
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* Indicates required question
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Writing for Wellbeing
Crafting for Wellbeing
Drama for Wellbeing
Drumming for Wellbeing
Woodwork for Wellbeing
Other:
First name of individual
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Your answer
Last name of individual
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Your answer
Telephone number
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Your answer
Email address
*
Your answer
Gender
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Male
Female
Other
Other:
Home country
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Your answer
Ethnicity
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Indian or British Indian
Pakistani or British Pakistani
Bangladeshi or British Bangladeshi
Chinese or British Chinese
Any other Asian background
Black Caribbean
Black African
Any other Black, Black British, or Caribbean background
Mixed White and Black Caribbean
Mixed White and Black African
Mixed White and Asian
Any other Mixed or multiple ethnic background
White English, Welsh, Scottish, Northern Irish or British
White Irish
Gypsy or Irish Traveller
Roma
Any other White background
Arab
Any other ethnic group
Language(s) spoken
*
Your answer
Date of birth
*
MM
/
DD
/
YYYY
Immigration status (if known)
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British citizen
Leave to remain
Asylum seeker
Refugee
Student visa
Other
Other:
Who referred you to us? / How did you find out about us?
*
Your answer
Please provide details of any food intolerants? (for refreshments purposes)
Your answer
Phone number and name of a contact for emergencies
*
Your answer
Is there anything we should know about your ability to be able to access our wellbeing services? (eg. communication needs, medical needs, sensory needs and triggers)
Your answer
Form completed by
*
Your answer
Data protection - we are committed to treating your personal data effectively under UK GDPR. The above data helps us to ensure we can support you effectively on your wellbeing journey. We may also use your data for statistical analysis/monitoring purposes. Your data will not be shared with third parties without informing you. Please indicate below your consent to our retaining your data for these purposes. For more details about our Data Protection Policy, or to withdraw consent, please contact the Data Protection Officer at
kaleidoarts@protonmail.com
.
*
I consent to Kaleido Arts for Wellbeing retaining my personal data as outlined above.
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